Patterns and risk factors associated with index Lower Extremity Amputations (LEA) among Type 2 Diabetes Mellitus (T2DM) patients in Fiji


      • T2DM patients with different ethnicities experience different LEAs.
      • Hypertension is most common co-morbidity among T2DM patients with Major LEA.
      • Patients with Major LEAs have higher death than patients with Minor LEAs.
      • Different factors are associated with occurrence of Major LEA among T2DM patients.



      To describe patterns of index (first ever) Lower Extremity Amputations (LEA) and to determine factors associated with their occurrence amongst Type 2 Diabetes Mellitus (T2DM) patients in Fiji.


      This cross-sectional study was conducted that adheres to the STROBE check lists for observational research among T2DM patients who experienced index LEA at the Colonial War Memorial Hospital (CWMH) in Fiji between 2011 and 2015. Demographic and clinical variables were extracted from patient folders. Univariate and multivariate logistic regression were used to determine factors associated with Major LEA. A p-value < 0.05 was considered significant.


      A total of 649 study participants were studied with the average age of index amputation was 58.4 years (±9.6 years, range 30–91 years). The average duration of T2DM was 9.5 ± 5.7 years. LEAs were more common amongst males (55%) and indigenous Fijians (71.8%). One-third of index LEA (33%) were major amputations. Factors associated with occurrence of Major LEA were poor Random Blood Sugar (RBS) levels (OR = 1.68, 95% CI: 1.01, 2.81), midfoot lesion (OR = 9.38 95% CI: 4.95, 19.52), septicaemia (OR = 2.42, 95% CI: 1.28, 4.57), low haemoglobin level (OR = 0.78 95% CI: 0.72, 0.86), and history of hypertension (OR = 0.58, 95% CI: 0.40, 0. 84).


      Results indicate that diabetic patients with foot infections present late to tertiary level care. Our findings also show an urgent need to strengthen primary care interventions and surveillance of both diabetes and diabetic LEA.


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        • Wild S.
        • et al.
        Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.
        Diabetes Care. 2004; 27: 1047-1053
        • Ndiaye F.K.
        • et al.
        Expression and functional assessment of candidate type 2 diabetes susceptibility genes identify four new genes contributing to human insulin secretion.
        Mol. Metab. 2017; 6: 459-470
        • Aslan O.
        • Demir M.
        • Koseoglu M.
        Kidney injury molecule levels in type 2 diabetes mellitus.
        J. Clin. Lab. Anal. 2016; 30: 1031-1036
        • Yoshida Y.
        • et al.
        Effect of health information technologies on glycemic control among patients with type 2 diabetes.
        Curr. Diab. Rep. 2018; 18: 130
        • Holman N.
        • Young B.
        • Gadsby R.
        Current prevalence of Type 1 and Type 2 diabetes in adults and children in the UK.
        Diabet. Med. 2015; 32: 1119
        • Bruno G.
        • et al.
        Incidence of type 1 and type 2 diabetes in adults aged 30–49 years: the population-based registry in the province of Turin, Italy.
        Diabetes Care. 2005; 28: 2613-2619
        • Saeedi P.
        • et al.
        Mortality attributable to diabetes in 20–79 years old adults, 2019 estimates: results from the International Diabetes Federation Diabetes Atlas.
        Diabetes Res. Clin. Pract. 2020; 108086
        • IDF
        IDF Diabetes Atlas, 6th Edition: Western Pacific at a Glance.
        2014 ([Cited 2015 24/10/15] Available from:
        • WHO
        Fiji Steps Survey.
        • IDF
        Bridges: Fiji.
        2015 ([24/10/15]; Available from:
        • Lin S.
        • et al.
        Diabetes and obesity trends in Fiji over 30 years: 在斐济过去的 30 年中糖尿病与肥胖的趋势.
        J. Diabetes. 2016; 8: 533-543
        • Weledji E.P.
        • Fokam P.
        Treatment of the diabetic foot - to amputate or not?.
        BMC Surg. 2014; 14: 1471-2482
        • Kalapatapu V.
        Lower Extremity Amputation.
        ([Cited 2018 15 March 2018] Available from:) UptoDate. com, 2017
        • Cook J.J.
        • Simonson D.C.
        Epidemiology and health care cost of diabetic foot problems.
        The Diabetic Foot. Springer, 2012: 17-32
        • Moxey P.
        • et al.
        Lower extremity amputations—a review of global variability in incidence.
        Diabet. Med. 2011; 28: 1144-1153
        • Greenfield S.
        • Nicolucci A.
        • Mattke S.
        Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Countries.
        • Agwu E.
        • Dafiewhare E.O.
        • Ekanem P.E.
        Possible Diabetic-Foot Complications in Sub-Saharan Africa.
        INTECH Open Access Publisher, 2011
        • Pendsey S.
        Reducing Diabetic Foot Problems and Limb Amputation: An Experience from India.
        INTECH Open Access Publisher, 2011
        • Boulton A.J.
        • et al.
        The global burden of diabetic foot disease.
        Lancet. 2005; 366: 1719-1724
        • Jesus-Silva S.
        • O.J
        • Brianezi M.
        • Silva M.
        • Krupa A.
        • Cardoso R.
        Analysis of risk factors related to minor nad major lower limb amputations at a tertiary hospital.
        J. Vasc. Surg. 2017; 16: 16-22
        • Narres M.
        • et al.
        Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: a systematic review.
        PLoS One. 2017; 12e0182081
        • Kroger K.
        Major and minor amputation rates what do they tell us?.
        Eur. Wound Manage. Assoc. J. 2015; 15: 65-67
        • Laclé A.
        • Valero-Juan L.F.
        Diabetes-related lower-extremity amputation incidence and risk factors: a prospective seven-year study in Costa Rica.
        Rev. Panam. Salud Pública. 2012; 32: 192-198
        • Yusof N.M.
        • et al.
        Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems.
        Singapore Med. J. 2015; 56: 626-631
        • Chaturvedi N.
        • et al.
        Risk factors, ethnic differences and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO Multinational Study of Vascular Disease in Diabetes.
        Diabetologia. 2001; 44: S65-S71
        • Resnick H.E.
        • Valsania P.
        • Phillips C.L.
        Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992.
        Arch. Intern. Med. 1999; 159: 2470-2475
        • AIHW
        Burden of Lower Limb Amputations Due to Diabetes in Australia. Australian Burden of Disease Study 2011.
        • Humphrey A.
        • et al.
        Diabetes and Nontraumatic Lower Extremity Amputations: incidence, risk factors, and prevention—a 12-year follow-up study in Nauru.
        Diabetes Care. 1996; 19: 710-714
        • Kumar K.
        • S.W
        • Ram S.
        • Khan S.
        • Cornelius M.
        • Tukana I.
        • et al.
        Descriptive analysis of diabetes-related amputations at the Colonial War Memorial Hospital, Fiji, 2010-2012.
        Public Health Action. 2014; 4: 155-158
        • WHO
        Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review.
        World Health Organization, 2001
        • Kahl L.
        • H. K
        Harriet Lane Handbook.
        Unbound medicine, 2018
        • Mohms F.
        Fiji Diabetes Guideline.
        third edition. Fiji Ministry of Health and Medical Services, 2012
        • Diabetes Management Guidelines
        Ministry of Health Government of Fiji 2012.
        third edition. 2012 (2012)
        • Canale S.
        • et al.
        Acute retroperitoneal hemorrhage complicating a xanthogranulomatous pyelonephritis.
        Eur. Radiol. 2007; 17: 1128-1129
        • Morrell S.
        • L.S
        • Tukana I.
        • Linhart C.
        • Taylor R.
        • Vatucawaqa P.
        • Magliano D.
        • Zimmet P.
        Diabetes incidence and projections from prevalence surveys in Fiji.
        Popul. Health Metr. 2016; 14: 1-8
        • Yang Y.
        • et al.
        Risk factors for lower extremity amputation among patients with diabetes in Singapore.
        J. Diabetes Complicat. 2011; 25: 382-386
        • Jain A.K.C.
        • Varma A.K.
        Major amputations in diabetes–an experience from a diabetic limb salvage centre in India.
        Diabetes. 2012; 14 (41.18)
        • Shojaiefard A.
        • Khorgami Z.
        • Larijani B.
        Independent risk factors for amputation in diabetic foot.
        Int. J. Diabetes Dev. 2008; 28: 32
        • Wirth R.B.
        • et al.
        Prevalence and risk factors for diabetes and diabetes-related amputations in American Indians in southern Arizona.
        Diabetes Care. 1993; 16: 354-356
        • Olenja J.
        Editorial: Health seeking behaviour in context.
        East Afr. Med. J. 2003; 80: 61-62
        • Latunji O.
        • Akinyemi O.
        Factors influencing health-seeking behaviour among civil servants in Ibadan, Nigeria.
        Annu. Ib. Postgrad. Med. 2018; 16: 52-60